Academic journal article Bulletin of the World Health Organization

An Ecological Study of Stillbirths in Mexico from 2000 to 2013/etude Ecologique De la Mortinatalite Au Mexique De 2000 a 2013/un Estudio Ecologico De Muertes Fetales En Mexico Desde 2000 Hasta 2013

Academic journal article Bulletin of the World Health Organization

An Ecological Study of Stillbirths in Mexico from 2000 to 2013/etude Ecologique De la Mortinatalite Au Mexique De 2000 a 2013/un Estudio Ecologico De Muertes Fetales En Mexico Desde 2000 Hasta 2013

Article excerpt

Introduction

In 2015, there were an estimated 2.6 million stillbirths worldwide, where a stillbirth was the death of a fetus with a gestational age of at least 28 weeks or with a birth weight of 1000 g or more, as defined by the World Health Organization. (1) Between 33% and 46% occurred during labour (i.e. intrapartum) and could have been prevented by simple measures. (2,3) Between 2000 and 2015, the global stillbirth rate decreased by an estimated 2% per year from 24.7 to 18.4 per 1000 births (i.e. live or dead). (1) In 2015, the majority of stillbirths (98%) occurred in low- and middle-income countries. The highest burden was in sub-Saharan Africa and in parts of south Asia, where the rate was 28.7 and 25.5 per 1000 births, respectively. Pakistan (43.1 per 1000 births), Nigeria (42.9 per 1000 births) and Chad (39.9 per 1000 births) had the highest rates. In contrast, six countries in Western Europe had an estimated stillbirth rate of 2 per 1000 births or less. (1)

Although stillbirths are associated with a wide range of factors (Fig. 1), governments can take action to reduce stillbirths. Between 2000 and 2012, the Mexican government implemented several interventions promoting maternal and perinatal health, including Fair Start in Life, (4) a national programme launched in 2001 that had a safe-motherhood component. In 2003, a health reform carried out under the System of Social Protection in Health established a new form of public health insurance, Seguro Popular. In addition, the Medical Insurance for a New Generation programme was launched in December 2006 to provide health coverage for all neonates. Further, special measures were introduced to expand coverage of antenatal care and to increase the number of institutional deliveries (i.e. the Healthy Pregnancy initiative in 2008) and to improve surveillance of maternal deaths. In 2009, the General Agreement for Collaborative Interinstitutional Care of Obstetric Emergencies was established. (5,6) Subsequently, maternal mortality declined to 49.0 per 100 000 live births in 2014 from 90.4 per 100000 in 1990. (7,8)

However, despite the importance of these interventions for public health, their impact on fetal outcomes has yet to be analysed and, in particular, few data on stillbirths have been reported for Mexico. The failure to count stillbirths makes it impossible to investigate their effect on families, on parental mental health, on economic and psychosocial development or on the health system. (9) In fact, counting and auditing fetal deaths are crucial for understanding perinatal outcomes and for implementing strategies to improve them. Moreover, the perinatal mortality rate is an indicator of quality of care and is essential for making international comparisons. (10)

The objectives of this study were: (i) to analyse trends in stillbirth rates in Mexico from 2000 to 2013; (ii) to identify sociodemographic factors associated with the stillbirth rate during this period; (iii) to investigate subnational variations in the rate; and (iv) to determine the proportion of stillbirths that occurred intrapartum in 2013. We hypothesized that perinatal outcomes have improved in Mexico over recent years because the country has implemented several programmes with that intent.

Methods

Our study was a population-based ecological study covering 2000 to 2013. We used aggregated data from the Mexican National Institute of Statistics and Geography, which records information on vital statistics every year and census data in selected years. In Mexico, about 95% of births occur in hospitals, which register live births and issue death certificates. (11) Consequently, our data represent population estimates. The information we obtained included fetal birth weight, fetal gestational age from the last menstrual period and selected maternal sociodemographic factors. We defined a stillbirth as a fetal death that occurred at a gestational age of 21 weeks or more: stillbirths were further classified as early (i. …

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